HomeMy WebLinkAbout006-439-02-4202-LUP-1991-198 X
Application for Land Use Permit
- County oL Sawyer ,��
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1'he undersigned hereby makes application for a Land Use PeLmit aud ayrees � '
that all work shall be done in accordance with the requirements oE the Sawyer °
County Zoning Ordinance and the laws and regulations of the State of Wisconsin.
PRIN'f - OSE OtJLY UL71CK 1NK/PIit7CiL .
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Owner Builder
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mailing address mailing address
. t: . . � . . � � _
city, state, zip� � city, state, zip
Building Land Use Zone District �;—'�
(� New ( ) Filling a
( ) Addition ( ) Uredging Lot size �j�� K f Zv 7 s �
( ) Alteration ( ) Gzading � ,;y in n
( ) Moving on ( ) Acres �
_ \
( ) ( 1
New Construction '
Size �_ fC wide Et wide
' r,
�_�_ f t long f t long � �
Floor area 11��' sq Et sq ft
� �
Total ligt � to peak to peak K�
Stories _�
�-�
No. oE bedrooms � rear lot line or -�-`-��� t��
year zound�) or (seasonal) � ��� � � �
� i �
Type of bldg or addition � i �
�(j Dwelling j i �
O Garage (1) (2) car i � w s
� �
O Storage building i i C rt
( ) �oatliouse � i v�i
( ) Livingroom � � � yI
( ) Bedroom i �
( ) Kitchen-dining �� i i
( ) Forch - enclosed/roofed � i � -�
( ) Deck - open - i i �
( ) r,i � '�
( ) � (AI�'
i �
�\Ii �X � �
Type of construction (V� 5{1FC� �
�
�Q Frame ( ) 61ock �� : ' W � '�'n
( ) Lo9 ( 1 Coucrete � �'"` ' ' � �X, j i��T}
( ) Pole ( ) Steel i � �� �4°:P�I��;'.�� �Qi:'�';�'� i
( ) Metal ( ) j � �y � `
i
� �
� T ; `'�
Construction cost $ � !�~� � j � ;iF;� � u��
' � 1 I �
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Vol :?j 5 Fg .�-� of deed � r � � ty � �
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�, �?'f:� � �
CSM Vol Pg i ; �+�` 6F�r i ro
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� � i n �
Cer. Soil 1'est /�� - _ j � � �,3
�f7_DV� ---`------CL road ------------------ o �
Sanitary Pezmit /� �V m� �O^-� `�r
rt-t--�
tt��Q��l\lJ 'D� �c�iU���`I cS`-C-�S'��- z
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Issued ��j rjj,�� ���1 Denied
�W�S �-D I 1 � l L�5
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. �. `� � � �C/.L.t GG�� -��C�� �
owner. Zoning Administrator ��1
//�
P� #b� �/yi
. Nisoonsia Dapartnent of Health and Sooisl Serviosa
Divieion of Health
. . � SEPTIC TANR PERMIT APPLICATION
TYPE OR USE BLACK INK - PLEASE PRINT
A, Oti1NER OF PROPERTY
� Address (Str�et, City� Zip Code)
,�� _ 7
�s � � - , •
. o - � , ..G• 1'tZ�. ,4.�
B, L�ATION OF PROPERTY WF�RE SYST FJILL BE CONSTF4TCTED ALTERED OR EXTENDED COUNTY U
Cheak Ones
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP�_ ���� (Blo�k, Lot, Sta, ) , ..�� � �--- �
. Ul.. �
C, IS LACAL PEAMIT REuUIRED FOR THIS WORK? _�YES No �� ,ct �PERMIT N�IDER
D. SEPTIC TANK CAPACITY �v GALLONS NEF1 INSTALLATION� REPLAC II'IENT ADDITION
MATERIALSt PREFAB CONCRETE POURED IN PLACE STEEL� 0'fHER
NLMBER OF TANKS TO BE INSTALLEDt
E.. TYPE OF OCCUPANCY I
Cheok Ones One or 'itiro Family Residenae� Cmnaercial Industrial Other (Speoify)
Number of persons to be Accormnodated� Number of Bedrooms�_
F, APPLICkNCES, ETC= Food Waste Grinder YES NO Automatic Clother Washer �, YES �NO
DisYnre.sher YES NO Automatia Potato Peeler YES NO
OTHER (specify� _ YES PIO
G. MASTER PLUrIDER MAKZNG INSTALLATION
Namet \�'��,C�`� \ VI.CJ [`�1. � C`��T_ Addrass: �'�i'.r'-�f a//�'�1 ,�--�r
_ �
C
SI�3NATURE OF APPLICANTs
Liaense Number� MP � I
ADDRESSi MP RSW �
H. (TO HE COMPLETED SY ISSUING AGErPP)
Date of Appliaation Faee Paid �
Vi
Permit Iasued (date) c-,v�`, ,� � ` �}`t.� P�rmit Numb�r � �,C[� �
Agent (neme) � � l�� �a��11�4 • Fors <���`��_�` �_4��� �'�"
tam� villa.ga, oity, courrty, �tn. speoi2'y) � �
�
. NOTEs The Appliaation aannot be aonsidered for filing urstil all of the abave questions ar� ansx�red j
and the fee paid. Agents will forxard application� the Pee of $1.00 for eaah septia taak assd �
tha thlyd oopy of the permit (ca:sary) to ths Divisian of Health. Cheoks and money ordar� should
be msde peyabl� to tha Diviaioa of Health. '
i
• i
COMPI,�TE OTMER SIDT► i '
�
� :
DOCUMENT NUMBER AFFIDAVIT
2 r�e 5141 EXISTING SEPTIC SYSTEM
ONE AND TWO FAMILY neWrirs.°*."�'�}' 1. � .
�:.�_,-us G-�•,:tl f
r,-„ �;<rnd t6e,� dn4 ot
If the existing septic system does meet the minimum re- 15�J� u,�p/;��
quirements for groundwater and bedrock depths and if it -� � .,`1,"!�����. � 7
is functioning, an addition to or replacement of a hab- -��' " � _� _ O ,S.
itable structure can be made in most instances without oi R�z�d� ^ �-."
updating the existing system. If the existing system ��—u'-- Bed�
is utilized for the addition, every attempt should be
made to locate and reserve an area which is suitable �
for a code complying replacement system for when the
system fails. If the addition will substantially in-
crease the wastewater discharge, the existing system RETURN TO J �
will be replaced with a code complying private sewage Sawyer County Zoning Admin �p
system. P.O. Box 668
Hayward WI 54843
owner(s) Scott R. Sammons and Terri L. Sammons
Mailing address Route 1 BoX 92A
Loretta Wisconsin 54896
Property description ''Part NW� of the SE� S 2, T 39N, R 4W. Parcel .14.2.
Vol 355 Records Pg 225. 9.76 acres. 006-439-02-4202. Town of Draper.
(� (we) Scott R. Sammons and Terri L. Sammons plan to
( ) Add onto existing dwelling
( ) Add onto existing mobile home
( ) Replace existing dwelling
(9() aeplace existing mobile home with construction of dwelling
The present private sewage system has been working satisfactorily as far as disposing
of wastes. If the present private sewage system does fail, it will be replaced with
one that is code complying.
.1��.�� �/Yy/,�:�2��/z �—�6 � //
Scott R. Sammons date
�n �,� � -,.,.,�..��� �2�-��
Terri L. Sammons aate
a
Personally came before me this ;•``�PRL �COC�
�{ F
�day of ��L.y , 19������� £N�rA(�!
�.�,�� �x ,�,�,�lcr �
Notary Publit� �`<� o
'�1\,\Cb County, Wisconsin�fECtE������5��
My Commission is expires � l�'-/�
Existing seotic system - Sanitary Permit ]3-�$7 ,
Date system stalled 06-23-73
��{�� /� ZA or AZA
�a���� s'� /95'�
date
This instrument was drafte'. by
Scott R. Sammons �4� � ��2 9 5
NAMEt
COUNTYt
� SEP7IC TANK PERMIT NUMBERi
REPORT ON SOIL PERCOLATION TEST l
AND 50IL BORINGS
TO
DIVISION OF HEALTH - PUJMBING SECTI@!
�- P,O,BOX 309, Mndiaon� Ais, 53701
� Purauant to N 62,20, Wie, Adm3niatravive Cod• . �
� - . - P E R C 0 L A T I 0 N T E S T
YES7 DEPTH CHARACTEIi OF SOIL HOURS ifATIIt TEST 4II� DROP IN HATER LSVEL INCE�S lIINUTES
NUfIDEA INCHES THICKNESS IN INCHES SINC& HOLE W HOLE INtEAYAL SECOND TO E7CT T0. LAST TO FALL
� � lst 4fE'PTED � OYERNIGIii' IN MINi1TES LAST PEAIOD LAST PERIOD PERI00 ON6 INCH
EXAI'�LE
P - 0 � 3E" ROP SOIL 10° C WY 26° 25 YES OR.NO 30 60
...., . . �f `' �
1 '.�` � . �' . � r , ' TCs :- : . .
( F' �
Z - _ .✓-•/ _:j � . . ,
y 1�� !U �
3 �!.�. i _ i _. <�.
RECORD DATA FROM LIUt7IMOM OF 3 TSST HOLES
COCpUTE SI2E OF ABSORpTION AAEA IN ACC03iD WITH H 62,20 NIS. ADMFN25TRATION CODE.
S 0 I L .B 0 R I N G S - MIIJINUM 36�' BELOId PROPOSEO ABSORPTION SYSTF�f
BOAINu TOTAL DEPTH DEPTH TO GROUND HATER DEP71i TO BEDAOCK
NUM3ER � INCF�S OBSERVEO EST IIIATED OBScRVED ESTIMATID CHkRACTEA OF SOIL WITN :HICHI7ESS IN INCH6S
EXAlP
B - 0 �� �� CK 0 OZ ^ C 8"' / 8" "
C/ � �; '�� .� � J ,� � / ,� / F �-/ /
1 �
�� [' �1 V /, � ' . •��/' � ;' /:.• /�
2 -
3
� t� '�t'� / ';i� :��- ;,� - f �
� � �"' � RECORD DATk PflOCi 7IN71�M4�OF_3 F
TYPE OF OCCUPANCYs� .. � . . . - '... � '
� AESIDENCE; NUIMdER OF BEDROOMS�_ OTHERt (SPECIFY) �'��•- '� �' -'' "� =-ti � NUlIDER OP PBRSONS
FOOD NASTE GRINDEA: YES_�NOy_UISFbtASk�R; yES� N0� �AUTOMATIC CLOTHES NASFgRp YES_� NO -�
� SFFLUENT DISPOSAL SYS7'EMi NEti7 � EXRETlSION 1wDITION� REPLAC229ENT
TILE SIZE__� N0. LZN, FEET����1.- TAENCH WIDTEf�..i�DEPTH�_�� rM1MBEA OF LINES_�_
SEfFAGE BfiDs LEM1.^,TH .��. � NIDTH ./.�:� �EPTH ' TILE SIZE_�NO, LINES_��_?-�
�SEEPAGE PITt INSIDE DIIS�TFR LIWID DEPTH
I� the uridersigncd, hereby oertlfy Lhat Lhe percole.tion tests reported on this form �ere made by me or under �y super-
�i vision in acoord with the prooedures and method specified in Chapter H 62,20 (3 ), Hisconsin Administrative Code� and
fthat the data recorded and ,loca lon of test holea are correcL to the bast of uty laiowledge and be11eP.
MAME I ) r �,'.' %,� f / �`,.. /;�; -- `� �� ,. TITLE
TYPE or PRINT� ' � �
REGISTAATION N0, OR MASTER PL[1MBER LICENSE NO,��
ADDRE55
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1 /
� DATE . � > � ��' SIGNATURE :-; ,+- �� ,� : �;���.�. ; - �_.,m -.
� � DO NOT WRITE IN SPACE BEIOW -�FOR DEPAR9TIENT USE ONLY
� pATE RECfiIYED ACCEPTED BY pg�Jp�p
FEE RECENED YALSD N0, PEAIITT N0,
. REYIEHED BY AppROVED � Dp�
INITIALS Y55 OR N0�
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